This is generally the last part of the complete physical examination. While it may cause the patient and perhaps you some embarrassment as well as discomfort, it provides important information and should not be skipped. Explain to the patient what you are going to do and why and then proceed. If they have not already done so, ask the patient to remove their underwear.
The "daVinci Anatomy Icon" denotes a link to related gross anatomy pictures. It is a means of communicating information to all providers who are involved in the care of a particular patient. It allows students and house staff an opportunity to demonstrate their ability to accumulate historical and examination based information, make use of their medical fund of knowledge, and derive a logical plan of attack.
It is an important medical-legal document. An instrument designed to torture Medical Students and Interns. Meant to cover unrelated bits of historical information. Should neither require the killing of more then one tree nor the use of more then one pen to write! Knowing what to include and what to leave out will be largely dependent on experience and your understanding of illness and pathophysiology.
If, for example, you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary risk-factors when writing the history. Until you gain experience, your write-ups will be somewhat poorly focused. Not to worry; this will change with time and exposure.
Several sample student write-ups can be found at the end of this section. One sentence that covers the dominant reason s for hospitalization. Smith is a 70 year old male admitted for evaluation of increasing chest pain. The HPI should provide enough information without being too inclusive.
Events that occurred after arrival are covered in a separate summary paragraph that follows the pre-hospital history. Some HPIs are rather straight forward.
If, for example, you are describing the course of an otherwise healthy 20 year old who presents with 3 days of cough, fever, and shortness of breath, you can focus on that time frame alone. It gets a bit more tricky when writing up patients with pre-existing illness es or a chronic, relapsing problem.
In such cases, it is important to give relevant past history "up front," as having an awareness of this data will provide contextual information that will allow the reader to better understand the most recent complaint.
If, for example, a patient with a long history of coronary artery disease presents with chest pain and shortness of breath, it might be written as follows: S is a 70 yr old male with known coronary artery disease who is: This represented a significant change in his anginal pattern, which is normally characterized as mild discomfort which occurs after walking vigorously for 8 or 9 blocks.
In addition, 1 day prior to admission, the pain briefly occurred while the patient was reading a book.
He has also noted swelling in his legs over this same time period and has awakened several times in the middle of the night, gasping for breath. In order to breathe comfortably at night, Mr. S now requires the use of 3 pillows, whereas in the past he was always able to lie flat on his back without difficulty.
S is known to have poorly controlled diabetes and hypertension.
He denies fevers, chills, cough, wheezing, nausea vomiting or other complaints. From a purely mechanical standpoint, note that historical information can be presented as a list in the case of Mr.
S, this refers to his cardiac catheterizations and other related data. This format is easy to read and makes bytes of chronological information readily apparent to your audience.
Knowing which past medical events are relevant to their area of current concern takes experience.Guidelines for the History and Physical Exam Write-up. Department of Medicine.
Boston University School of Medicine. Revised January 28, Introductory Statement with Chief Complaint: is a brief statement explaining the reason the patient presented to the . The links below are to actual H&Ps written by UNC students during their inpatient clerkship rotations.
The students have granted permission to have these H&Ps posted on the website as examples. Sample Write-Ups Sample Neurological H&P CC: The patient is a year-old right-handed woman with a history of chronic headaches who complains of acute onset of double vision and right eyelid droopiness three days ago.
Sample Write-up. An example write-up is given below to guide the students towards what will be expected for their formal history and physical write-ups. It is also on Blackboard. Physical Exam. Vitals: At the time of my examination, the patient is afebrile with temperature of degrees Celsius.
His blood pressure is / Guidelines for the History and Physical Exam Write-up. Department of Medicine. Boston University School of Medicine.
Revised January 28, . PEDIATRIC HISTORY & PHYSICAL EXAM (CHILDREN ARE NOT JUST LITTLE ADULTS)-HISTORY- Learning Objectives: 1. To understand the content differences in obtaining a .